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Age and Ageing Advance Access published online on August 7, 2008
Age and Ageing, doi:10.1093/ageing/afn134
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Copyright © The Author 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.

Urinary incontinence in stroke: results from the UK National Sentinel Audits of Stroke 1998–2004

Dan Wilson1,*, Derek Lowe2, ALEX Hoffman3, Anthony Rudd4 and Adrian Wagg5

1 Consultant Physician, Department of Clinical Gerontology, Kings College Hospital, NHS Foundation Trust, Denmark Hill, London SE5 9PJ, UK
2 Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London NW1 4LE, UK
3 Stroke Programme Manager, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London NW1 4LE, UK
4 Programme Director for Stroke, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London NW1 4LE, UK
5 Associate Director, Continence, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London NW1 4LE, UK

Address correspondence to: Dan. Wilson. Tel: 020 3299 6088; Fax: 020 3299 6476. Email: Dan.wilson{at}kch.nhs.uk


   Abstract
Top
 Abstract
Introduction
 Method
 Results
 Discussion
 Key points
 References
 
Background: urinary incontinence (UI) after stroke is associated with significant morbidity and mortality. The UK National Sentinel Audits of Stroke have collected data on UI which has not previously been reported.

Methods: data on standards relating to both organisations and process of care were extracted from the audits to look for trends in service provision, continence care planning and discharge destination of incontinent versus continent stroke survivors. In addition, 2004 data was analysed statistically to look for a link between stroke units meeting certain standards and the likelihood of patients having continence plans.

Results: UI rates have changed little over the four audit cycles. The influence of UI on discharge destination has also altered little. Stroke unit care is more strongly associated with management planning for UI in stroke.

Keywords: stroke, urinary incontinence, medical audit, elderly


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion
 Key points
 References
 
Stroke is a leading cause of adult disability in the United Kingdom and the third leading cause of death [1]. Urinary incontinence (UI) is common among stroke survivors [2–5] and is associated with higher levels of mortality [6], disability [7], and discharge to institutional care [8] than in continent survivors. In previously continent stroke survivors at 1 week, UI was found in 35% in one study [5]. Higher rates have been found at the time of maximum stroke severity [4] and in older people [9]. These rates have been shown to decline to as low as 19% by 6 months although half of those who were incontinent at presentation died during that time [3]. Being younger, having a lacunar stroke and greater functional independence are associated with an increased likelihood of regaining continence [3]. Other factors that influence continence in stroke include cognitive impairment, the ability to communicate, mobility and conscious level [10, 11].

The National Sentinel Audits of Stroke carried out by the Royal College of Physicians Clinical Effectiveness and Evaluation Unit since 1998 aims to describe the current state of stroke services in the United Kingdom and promote better stroke care by auditing both organisation of stroke services and the clinical process that takes place within each organisation [12–15]. Results are compared with standards promoted nationally such as those in the Royal College of Physicians National Clinical Guidelines for Stroke [16] and the standards set in the National Service Framework for older people [17]. The audits have included questions on the organisation and process of care for people with stroke who also have UI. These have not been reported in any detail.

Given the importance of UI in stroke survivors, this study aimed to describe the following:

  • The distribution of UI following stroke.
  • What organisational elements of service are in place.
  • What care people received.
  • Trends in service provision, which might have led to an improvement in the quality of continence care provided to patients with stroke over the timescale of the audit.
  • Outcomes associated with UI and stroke.


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  		Table 1. Distribution of urinary incontinence (UI) before stroke, 1 week after stroke, at discharge from hospital and of a plan to promote continence in UI patients. Results from the first four rounds of the National Stroke Audit

 

   Method
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 Abstract
 Introduction
 Method
Results
 Discussion
 Key points
 References
 
Data from the National Stroke audits for England, Wales and Northern Ireland of 1998, 1999, 2001–2002 and 2004 were used to examine evidence-based quality measures (standards) in organisation of services and provision of care that might impact on patients with UI.

Organisational factors were as follows:

  • Access to organised stroke care in stroke units.
  • Regular team meetings including all staff.
  • Ready access to reference information on functional tools used locally (i.e. Barthel).
  • Ready access to practice guidelines on continence management.
  • Specialist nursing support for continence advice.
  • In-house programme of continuing education.

Processes of care influencing UI in stroke were the following:

  • Documentation of newly developed UI.
  • Changes in continence over time.
  • Documented care plans to promote continence.
  • Reasons for catheter use.
  • Quantity of catheter usage.

Each trust/hospital site taking part in the audit was required to complete one organisational audit proforma and to submit clinical data on 40 consecutive patients. Data are expressed in percentage and absolute terms and where data were not applicable or missing the denominator is adjusted accordingly. The audit designated a priori specified circumstances where measures did not apply. When asking whether there was a plan to promote urinary continence the ‘NO BUT’ criterion applied if the patient was continent, had died within 7 days of stroke, or was unconscious or receiving palliative care.

UI rates were calculated from modified Barthel scores that included catheterised patients. Catheterisation rates may confound UI distribution rates as occasionally continent patients are catheterised in practice.

Data from the 1999 audit had a higher number of patients still in hospital at the time of data collection. More severe cases with longer lengths of stay were under-represented and had an impact upon the analysis of discharge destination.

Analyses were performed within the Clinical Effectiveness and Evaluation Unit (CEEu) using SPSS v14. The influence of organisational standards in stroke units to patients having a continence plan was investigated with data from the most recent audit (2004). Influence of individual organisational standards was assessed using the Mann–Whitney test and of the number of standards using Spearman correlation (r).


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion
 Key points
 References
 
Demographics
The age distribution of patients across the audits was very similar (mean age 72–73 years for men and 77–79 years for women); 46–48% of the audit sample was male. Other case mix variables (including pre-admission disability as measured by Barthel score and pre-admission accommodation) also remained very similar over the four audits (results not shown).

The UI rates before stroke (8–9%), at 1 week after stroke (39–44%), and at discharge (15–20%) remained similar over time (Table 1). Missing data for Barthel scores ranged from 24 to 31% pre-stroke and 17–39% post-stroke, improving with time.

Organisation of care
Organisational standards relevant to UI care were consistently better achieved in stroke units than elsewhere within hospitals (Table 2). Away from the stroke unit only the provision of specialist nursing support was anything like that seen for stroke units. Over time the trend was for minor improvement in stroke units but some deterioration in other wards. The 2004 data indicated that 54% of stroke patients were not treated in a specialist stroke unit.


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  		Table 2. Organisational standards that might impact on urinary incontinence in stroke survivors, whether met in all wards and in stroke units. Results from the first four rounds of the National Stroke Audit

 
Process of care
The percentage of patients with a plan to promote continence improved over the first three audits from 47 to 62% but fell back to 58% in 2004 (Table 2).

In 2004, only 58% (1,388/2,386) of applicable patients had a plan to promote urinary continence. Those sites with stroke units that met an organisational standard had proportionately more patients with a plan than sites whose stroke units did not meet that standard (Table 3). There was an association between the proportion with care plans and the number of organisational standards met in stroke units (r = 0.32, P < 0.001), the median percentage was 67% when all five standards were met (91 sites), 51% for four standards (60 sites), 43% for three (21 sites) and 40% for less than three (19 sites). Missing data rates were low, at most 3% in any audit, for this patient standard (to have a continence plan), whilst the percentage of patients to whom the standard could apply ranged from 28 to 38%.


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  		Table 3. Relation of organisational standards to patients having a care plan to promote urinary continence, results available for 191 stroke units from the 2004 National Stroke Audit

 
The percentage of sites having a stroke unit has risen from 50% (105/210) in 1998 and 55% (96/173) in 1999 to 73% (175/240) in 2001–2002 and 79% (201/256) in 2004.

Despite this improved access to stroke unit care, in 2004 only 46% of stroke sufferers (4,014/8,697) spent some of their time in a stroke unit and only 40% (3,504/8,696) spent more than half their stay in a dedicated stroke bed.

Outcomes
The 2004 audit gave extra information on indwelling urinary catheterisation, with a rate of 30% (2,609/8,653) in the first week after admission. Reasons for catheter insertion indicated that 12% of all admissions were catheterised for UI, in another 8% either for urinary retention or for fluid balance monitoring. There was no documented reason for 7% of patients. Other specific reasons were documented in only 3% (either as pre-existing catheter or critical skin care).

The choice of discharge destination for those with UI (Barthel score 0) has changed little over time. In 2004, 62% (548/885) of incontinent patients were discharged to a care home compared with 5% (223/4,107) who were continent. For patients previously living independently, who were incontinent at discharge, 52% (355/682) went to care homes. Return to independent living was achieved for 91% (3,749/4,107) of continent stroke survivors.


   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
Key points
 References
 
Prevalence of UI in the first week after stroke varied little over the course of the first three audits. Although missing Barthel data were high in the audits other studies have found similar distributions in the first 2 weeks of between 39% [2] and 54% [5]. Resolution of UI in relation to discharge saw a reduction in the amount of incontinence which was stable over time—suggesting little influence of better stroke unit care over that period. Whilst there have been considerable improvements in certain areas, such as the number of stroke units in the United Kingdom, the number of patients spending time in those units, and use of certain secondary prevention medications [15], there appears to be less progress when it comes to the treatment of UI. However, organised stroke care and access to specialist continence nurses were the key standards that made a plan to promote urinary continence more likely.

A recent Cochrane collaboration review of prevention and treatment of UI after stroke found very limited evidence upon which to base its recommendation for management [18]. Of the seven eligible studies reviewed, two had positive outcomes; one favouring structured assessment and management in early rehabilitation and the other assessment and management by Continence Nurse Practitioners in a community setting, both versus usual care. As the only evidence-based treatment for UI post-stroke in inpatients appears to be structured assessment and management then our results add further weight to the notion that stroke survivors with UI should be treated by those with appropriate expertise in specialist units unless exceptional circumstances exist. Dedicated stroke services appear to have lead to an increase in the rates of team-working and guidelines for assessment and management of UI within stroke units.

Stroke survivors who could not gain access to specialised services were much less likely to have a UI management plan; access to continence guidelines and staff education fell. Given that more and more sites have opened stroke units the future trend is for better UI care so long as more patients are actually treated in stroke units. Higher numbers of stroke survivors with UI were discharged into institutional care, in keeping with other published data. Any reduction in this number due to management of incontinence should both reduce costs and improve patient experiences.

Catheterisation for UI not due to retention of urine seems to be relatively common. Whilst recent guidance suggests consideration of catheters for relief of distress caused by other forms of UI in women it stresses that this may be ineffective for overactive bladder [19]. In addition good practice would support catheterisation for UI as a method of containment only as a last resort, given the potential for catheters to cause harm (for instance through infection or precipitation of delirium).

Although specific trials looking at interventions in UI post-stroke are lacking there is evidence that UI sufferers without stroke can benefit from treatment. Both pharmacological and non-pharmacological measures can reduce UI rates in overactive bladder [20] and there are well-described surgical procedures for stress incontinence [21]. There is no evidence to suggest that these interventions are not applicable to the stroke population and in the absence of randomised trials in UI post-stroke it would seem wise to at least explore some of these measures. There are substantial costs associated with UI [22] and with placement in long-term care facilities.

The National Sentinel Audits of Stroke are important both in describing what is happening in the rapidly developing area of stroke medicine and in driving change. Because the audit tools have by necessity been developed and refined over time there have been some changes in the way certain questions have been asked. This inevitably makes direct comparisons of some data more difficult.

Clearly without well-designed randomised trials of specific treatments there will always be uncertainty. We hope that by highlighting the issues surrounding the occurrence and management of UI in stroke more attention will be paid to this troublesome, debilitating condition.


   Key points
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Key points
References
 

  • UI after stroke is a common problem associated with a poor outcome.
  • Results from the Royal College of Physicians’ National Sentinel Audits of Stroke reflect this association.
  • In the audits, plans to promote urinary continence were more likely to occur in stroke units, and that likelihood increased in units meeting higher organisational standards.
  • The 2004 audit highlights a disproportionate use of catheters to manage UI.


   Conflicts of interest
 
None


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Key points
 References
 

  1. Wolfe CD. The impact of stroke. British Medical Bulletin (2000) 56:275–86.[Abstract/Free Full Text]
  2. Brocklehurst JC, Andrews K, Richards B, et al. Incidence and correlates of incontinence in stroke patients. J Am Geriatr Soc (1985) 33:540–2.[Web of Science][Medline]
  3. Nakayama H, Jorgensen HS, Pedersen MA, et al, The Copenhagen Stroke Study. Prevalence and risk factors of incontinence after stroke. Stroke (1997) 28:58–62.[Abstract/Free Full Text]
  4. Lawrence ES, Coshall C, Dundas R, et al. Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke (2001) 32:1279–84.[Abstract/Free Full Text]
  5. Kolominsky-Rabas PL, Hilz M-J, Neundoerfer B, et al. Impact of urinary incontinence after stroke: results from a prospective population-based stroke register. Neurourol Urodyn (2003) 22:322–7.[CrossRef][Web of Science][Medline]
  6. Anderson CS, Jamrozik KD, Broadhurst RJ, et al, Results from the Perth Community Stroke Study. Predicting survival for 1 year among different subtypes of stroke. Stroke (1994) 25:1935–44.[Abstract]
  7. Taub NA, Wolfe CDA, Richardson E, et al. Predicting the disability of first-time stroke sufferers at 1 year. 12-month follow-up of a population-based cohort in southeast England. Stroke (1994) 25:352–7.[Abstract]
  8. Patel M, Coshall C, Rudd AG, et al. Natural history and effects on 2-year outcomes of urinary incontinence after stroke. Stroke (2001) 32:122–7.[Abstract/Free Full Text]
  9. Kalra L, Smith DH, Crome P. Stroke in patients aged over 75 years: outcome and predictors. Postgrad Med (1993) 69:33–6.[Abstract/Free Full Text]
  10. Gelber DA, Good DC, Laven LJ, et al. Causes of urinary incontinence after acute hemispheric stroke. Stroke (1993) 24:378–82.[Abstract/Free Full Text]
  11. Borrie MJ, Campbell AJ, Caradoc-Davies TH, et al. Urinary incontinence after stroke: a prospective study. Age Ageing (1986) 15:177–81.[Abstract/Free Full Text]
  12. Royal College of Physicians of London. Clinical Effectiveness and Evaluation Unit, National Sentinel Audit of Stroke (1998).
  13. Royal College of Physicians of London. Clinical Effectiveness and Evaluation Unit, National Sentinel Audit of Stroke (1999).
  14. Royal College of Physicians of London. Clinical Effectiveness and Evaluation Unit, National Sentinel Audit of Stroke (2002).
  15. Royal College of Physicians of London. Clinical Effectiveness and Evaluation Unit, National Sentinel Audit of Stroke (2004).
  16. Royal College of Physicians. National Clinical Guidelines for Stroke (2004) 2nd edition. London: RCP. Prepared by the Intercollegiate Stroke Working Party.
  17. Dept of Health. National Service Framework for Older People (2001).
  18. Thomas LH, Barrett J, Cross S, et al. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev (2005) (issue 3). Art. no. CD004462.pub.2, DOI:10.1002/14651858.CD004462.pub.2.
  19. NICE. Urinary Incontinence: The Management of Urinary Incontinence in Women (2006) www.nice.org.uk/CG040.
  20. Wagg A, Cohen M. Medical therapy for the overactive bladder in the elderly. Age Ageing (2002) 31:241–6.[Abstract/Free Full Text]
  21. Thakar R, Stanton S. Management of urinary incontinence in Women. BMJ (2000) 321:1326–31.[Free Full Text]
  22. Continence Foundation. Making the Case for Investment in an Integrated Continence Service: A Source Book for Continence Services (2000) London: CF.
Received 30 August 2007; accepted in revised form 26 February 2008.


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